Provider Demographics
NPI:1184062259
Name:EXTENDED CARE PORTFOLIO FLORIDA TENANT, LLC
Entity type:Organization
Organization Name:EXTENDED CARE PORTFOLIO FLORIDA TENANT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-726-3980
Mailing Address - Street 1:1785 HANCOCK ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-2073
Mailing Address - Country:US
Mailing Address - Phone:619-296-9000
Mailing Address - Fax:
Practice Address - Street 1:4760 S JOG RD
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33467-5119
Practice Address - Country:US
Practice Address - Phone:561-434-0434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EXTENDED CARE PORTFOLIOTENANT, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-11
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL99310400000X
FLAL9409310400000X, 310400000X
FLAL9666310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility